MEDICARE: ROOTED HERITAGE LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1316872252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTED HERITAGE LLC

Provider Business Mailing Address
First Line	:	140 OAKSHIRE DR E
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-8528
Country	:	US
Telephone Number	:	309-846-3371
Fax Number	:

Provider Business Practice Location Address
First Line	:	4956 BENCHMARK CENTRE DR STE C
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-7605
Country	:	US
Telephone Number	:	618-622-9533
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CHARLES C HINES III
Credential	:	DMD
Telephone Number	:	309-846-3371

Provider Enumeration Date	:	06/13/2026
Last Update Date	:	06/13/2026

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Directions to “ROOTED HERITAGE LLC ” Practice Location

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