Provider Demographics
NPI:1053654475
Name:VIEGO, REBECA
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:VIEGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 SAN MATEO BLVD NE APT 1124
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2612
Mailing Address - Country:US
Mailing Address - Phone:305-926-3121
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHERN BLVD SE STE B1
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3761
Practice Address - Country:US
Practice Address - Phone:505-892-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN205341223G0001X
NMDD52541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice