Provider Demographics
NPI:1134466279
Name:SLYBY, DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:SLYBY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 EAST STATE BLVD
Mailing Address - Street 2:B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815
Mailing Address - Country:US
Mailing Address - Phone:260-484-0725
Mailing Address - Fax:
Practice Address - Street 1:4606 E STATE BLVD
Practice Address - Street 2:B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6993
Practice Address - Country:US
Practice Address - Phone:260-484-0725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200258780AMedicaid