Provider Demographics
NPI:1063508398
Name:LISETTE BAECHTOLD, D.M.D., M.S.
Entity Type:Organization
Organization Name:LISETTE BAECHTOLD, D.M.D., M.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:LISETTE
Authorized Official - Last Name:BAECHTOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:859-626-7977
Mailing Address - Street 1:2006 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8167
Mailing Address - Country:US
Mailing Address - Phone:859-626-7977
Mailing Address - Fax:859-626-5103
Practice Address - Street 1:2006 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8167
Practice Address - Country:US
Practice Address - Phone:859-626-7977
Practice Address - Fax:859-626-5103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6635122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60066354Medicaid
KY1603579OtherUNITED CONCORDIA
KY45004306Medicaid