Provider Demographics
NPI:1750695144
Name:CANALES, ELLYSSE (DDS)
Entity type:Individual
Prefix:DR
First Name:ELLYSSE
Middle Name:
Last Name:CANALES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 NW 24TH ST
Mailing Address - Street 2:323 NW 24TH STREET
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:210-436-7126
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25653122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist