Provider Demographics
NPI:1417484510
Name:IDIALE, BENJAMIN AKPOCHA (LDO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:AKPOCHA
Last Name:IDIALE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 STONE MOUNTAIN HWY STE B
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3455
Mailing Address - Country:US
Mailing Address - Phone:404-578-9117
Mailing Address - Fax:
Practice Address - Street 1:5226 STONE MOUNTAIN HWY STE B
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3455
Practice Address - Country:US
Practice Address - Phone:404-578-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002703156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician