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General NPI Number Information
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NPI Number | 1316872252
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Entity Type | Organization
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Legal Business Name | ROOTED HERITAGE LLC
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Dates
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Enumeration Date | 06/13/2026
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Last Update Date | 06/13/2026
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Provider Practice Location Address
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Address Line | 4956 BENCHMARK CENTRE DR STE C
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City | SWANSEA
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State | IL
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Zip | 62226-7605
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Country | US
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Telephone | 618-622-9533
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Fax |
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Provider Business Mailing Address
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Address Line | 140 OAKSHIRE DR E
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City | GLEN CARBON
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State | IL
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Zip | 62034-8528
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Country | US
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Telephone | 309-846-3371
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. CHARLES C HINES III
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Credential | DMD
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Telephone | 309-846-3371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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