MEDICARE: PEDIATRIC DENTISTRY OF PORTLAND LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	D6853	OR

General Provider Information

NPI Number	:	1679924526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY OF PORTLAND LLC

Provider Business Mailing Address
First Line	:	2811 NE WASCO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1771
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2811 NE WASCO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1771
Country	:	US
Telephone Number	:	503-284-5678
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NOEL LARSEN
Credential	:	DMD
Telephone Number	:	503-284-5678

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	06/22/2016

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