Healthcare Provider Details

I. General information

NPI: 1053654475
Provider Name (Legal Business Name): REBECA VIEGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 SOUTHERN BLVD SE STE B1
RIO RANCHO NM
87124-3761
US

IV. Provider business mailing address

9100 SAN MATEO BLVD NE APT 1124
ALBUQUERQUE NM
87113-2612
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-0111
  • Fax:
Mailing address:
  • Phone: 305-926-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN20534
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5254
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: