Provider Demographics
NPI:1295821551
Name:BAECHTOLD, LESLIE LISETTE (DMD, MS)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LISETTE
Last Name:BAECHTOLD
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
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
Practice Address - Country:US
Practice Address - Phone:859-626-7977
Practice Address - Fax:859-626-5103
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66341223G0001X
KY6635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1603579OtherUNITED CONCORDIA
KY60066354Medicaid
KY45004306Medicaid