Provider Demographics
NPI:1659421089
Name:BAECHLE, MARY ANNE
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANNE
Last Name:BAECHLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 OLD HEARTH CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1510
Mailing Address - Country:US
Mailing Address - Phone:804-360-8756
Mailing Address - Fax:
Practice Address - Street 1:521 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5045
Practice Address - Country:US
Practice Address - Phone:804-628-0213
Practice Address - Fax:804-828-2185
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH71-0001631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0411000046OtherDENTAL FULL TIME FACULTY LICENSE
OH30-022482OtherSTATE DENTAL LICENSE
TX19478OtherSTATE DENTAL LICENSE
OH71-000163OtherLIMITED TEACHING LICENSE