MEDICARE: DR. ELLYSSE CANALES DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	25653	TX
2	1223G0001X	General Practice Dentistry	25653	TX

General Provider Information

NPI Number	:	1750695144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLYSSE CANALES DDS

Provider Business Mailing Address
First Line	:	323 NW 24TH ST
Second Line	:	323 NW 24TH STREET
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3209
Country	:	US
Telephone Number	:	210-436-6261
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 NW 24TH ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78207-3209
Country	:	US
Telephone Number	:	210-436-6261
Fax Number	:	210-436-7126

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2010
Last Update Date	:	01/15/2014

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