Healthcare Provider Details

I. General information

NPI: 1831072529
Provider Name (Legal Business Name): VIVIANA A REPENNING
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 COORS BLVD NW
ALBUQUERQUE NM
87120-1870
US

IV. Provider business mailing address

9635 BIG ROCK DR NW
ALBUQUERQUE NM
87114-3027
US

V. Phone/Fax

Practice location:
  • Phone: 505-431-9740
  • Fax:
Mailing address:
  • Phone: 720-289-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2025-0145
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: