MEDICARE: S. GRAYSON EDDY, D.D.S.,P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS 1916	TN

General Provider Information

NPI Number	:	1215944988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. GRAYSON EDDY, D.D.S.,P.C.

Provider Business Mailing Address
First Line	:	3221 W GOVERNOR JOHN SEVIER HWY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37920-5540
Country	:	US
Telephone Number	:	865-579-3000
Fax Number	:	865-579-3056

Provider Business Practice Location Address
First Line	:	3221 W GOVERNOR JOHN SEVIER HWY
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37920-5540
Country	:	US
Telephone Number	:	865-579-3000
Fax Number	:	865-579-3056

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMUEL GRAYSON EDDY JR.
Credential	:	D.D.S.
Telephone Number	:	865-579-3000

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	08/31/2007

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