Provider Demographics
NPI:1740310838
Name:DOMINGUEZ-MATSUMOTO, VIRGINIA (DDS)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:DOMINGUEZ-MATSUMOTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3468 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4775
Mailing Address - Country:US
Mailing Address - Phone:847-212-0931
Mailing Address - Fax:312-214-4153
Practice Address - Street 1:3250 N ARLINGTON HEIGHTS RD STE 300
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1563
Practice Address - Country:US
Practice Address - Phone:847-506-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0217751223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health