Provider Demographics
NPI:1801229885
Name:ELLYSSE CANALES DDS PC
Entity Type:Organization
Organization Name:ELLYSSE CANALES DDS PC
Other - Org Name:24TH STREET DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLYSSE
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:CANALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-436-6261
Mailing Address - Street 1:323 NW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3209
Mailing Address - Country:US
Mailing Address - Phone:210-436-6261
Mailing Address - Fax:
Practice Address - Street 1:323 NW 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3209
Practice Address - Country:US
Practice Address - Phone:210-436-6261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX256531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty