=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699696229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOGOLLON FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2026
-----------------------------------------------------
Last Update Date | 07/21/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3367 BUCKSKIN RD
-----------------------------------------------------
City | OVERGAARD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85933-3298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-535-5886
-----------------------------------------------------
Fax | 928-535-5887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3367 BUCKSKIN RD # 100
-----------------------------------------------------
City | OVERGAARD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85933-3298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-535-5886
-----------------------------------------------------
Fax | 928-535-5887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/ OWNER
-----------------------------------------------------
Name | DR. JEFFREY ANDERSEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 928-535-5886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------