Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019-021775 | IL |
N | 1223D0001X | Dental Public Health | 019-021775 | IL |
NPI | 1740310838 |
---|---|
Provider Name | Virginia Dominguez-Matsumoto |
First Address | Hoffman Estates, IL 60067-4775 |
Second Address | Arlington Heights, IL 60004-1563 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2007 |
Last Update Date | 23/04/2021 |