Healthcare Provider Details

I. General information

NPI: 1164344834
Provider Name (Legal Business Name): MOGOLLON FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3367 BUCKSKIN RD # 100
OVERGAARD AZ
85933
US

IV. Provider business mailing address

PO BOX 100
OVERGAARD AZ
85933-0100
US

V. Phone/Fax

Practice location:
  • Phone: 928-535-5886
  • Fax: 928-535-5887
Mailing address:
  • Phone: 928-535-5886
  • Fax: 928-535-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY ANDERSEN
Title or Position: DENTIST/ OWNER
Credential: DO
Phone: 928-535-5886