Healthcare Provider Details

I. General information

NPI: 1679496095
Provider Name (Legal Business Name): PEORIA VALLEY FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7017 W IRMA LN
GLENDALE AZ
85308-9474
US

IV. Provider business mailing address

7017 W IRMA LN
GLENDALE AZ
85308-9474
US

V. Phone/Fax

Practice location:
  • Phone: 406-544-1961
  • Fax:
Mailing address:
  • Phone: 406-544-1961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC LARSON
Title or Position: OWNER
Credential: DMD
Phone: 406-544-1961