Provider Demographics
NPI:1366626715
Name:CANALE, STEPHEN T (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:CANALE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:LA PUSH
Mailing Address - State:WA
Mailing Address - Zip Code:98350-0189
Mailing Address - Country:US
Mailing Address - Phone:360-374-6984
Mailing Address - Fax:360-374-5448
Practice Address - Street 1:560 QUILEUTE HEIGHTS
Practice Address - Street 2:
Practice Address - City:LAPUSH
Practice Address - State:WA
Practice Address - Zip Code:98350
Practice Address - Country:US
Practice Address - Phone:360-374-6984
Practice Address - Fax:360-374-5448
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000111531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5400221Medicaid
WA7084486Medicaid