Provider Demographics
NPI:1144661125
Name:JOHNDREAU, STEPHEN WADE (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WADE
Last Name:JOHNDREAU
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 1:1 WAHOO DRIVE
Mailing Address - Street 2:ATTN: MR. MARK MAMMOTH
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2377
Mailing Address - Fax:860-694-2590
Practice Address - Street 1:805 PINECREST DR
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-2845
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist