Provider Demographics
NPI:1215959325
Name:DAVID G. SLYBY D.D.S. P.C.
Entity type:Organization
Organization Name:DAVID G. SLYBY D.D.S. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SLYBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-484-0725
Mailing Address - Street 1:4606 E STATE BLVD
Mailing Address - Street 2:B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6993
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010192A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200258780AMedicaid