=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679496095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEORIA VALLEY FAMILY DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2026
-----------------------------------------------------
Last Update Date | 08/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7017 W IRMA LN
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-544-1961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7017 W IRMA LN
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-9474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-544-1961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIC LARSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 406-544-1961
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------